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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE November 29,202'PERMIT# BLDG-22-003068
JOBSITE ADDRESS 26 BLUEBERRY PATH VILLAGE OWNER'S NAME LAROCQUE ROBERT C
G OWNER ADDRESS 26 BLUEBERRY PATH YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General
Laws,and that my signature on this permit application waives this requirement,
SIGNATURE OF OWNER OR AGENT
i hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my
knowledge and that at plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME scotthohmann LICENSE# 12430 SIGNATURE
MP❑MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: ADDRESS. 9 fieldstone,
CITY norwell STATE MA ZIP 02061 TEL
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